|Year : 2016 | Volume
| Issue : 2 | Page : 147-150
Ovarian ectopic pregnancy: A case report
Sushil Ghanshyam Kachewar1, Smita Balwant Sankaye2
1 Department of Radio Diagnosis, PDVVPF`s Medical College, Ahmednagar, Maharashtra, India
2 Department of Pathology, SKNMC and GH, Pune, Maharashtra, India
|Date of Web Publication||31-Aug-2016|
Sushil Ghanshyam Kachewar
PDVVPF`s Medical College, Ahmednagar, Maharashtra - 414 311, Maharashtra
Source of Support: None, Conflict of Interest: None
Although ovarian ectopic pregnancy is rare, nevertheless, it is an important source of morbidity for women of childbearing age. Its incidence is on rise following the use of ovulation-inducing agents as well as after the increased usage of assisted reproductive technology. We report a case of a natural non-assisted right ovarian ectopic pregnancy detected primarily on transvaginal ultrasound in a lady who came with pain in the right lower abdomen and was subsequently confirmed at surgery and proven on histopathology. Judicious use of ultrasound in an appropriate clinical setting can thus prevent mishaps and enable better management of such conditions.
Keywords: Doppler, ectopic pregnancy, imaging, ovary, ultrasound
|How to cite this article:|
Kachewar SG, Sankaye SB. Ovarian ectopic pregnancy: A case report. J Mahatma Gandhi Inst Med Sci 2016;21:147-50
| Introduction|| |
Whenever the embryo is implanted outside the normal intrauterine cavity, it is known as an ectopic pregnancy (EP). When such ectopic implantation occurs in an ovary, it is known as an ovarian pregnancy (OP), meaning an ovarian ectopic pregnancy. The fertilized ovum is thus retained inside the ovary. The Spiegelberg criteria for diagnosing ovarian pregnancies are:
The fallopian tube on the ipsilateral side must be intact, the fetal sac must be intra ovarian, The ovary must be connected to the uterus by the ovarian ligament and the ovarian tissue must be located in the sac wall.
Following a natural conception, OP is seen in one in 7000–16,000 deliveries, and forms almost 1–3% of all ectopic gestations. With an increase in the use of assisted reproductive techniques, the cases of OP are also increasing.
High-resolution transvaginal ultrasonography (TVS) can beautifully demonstrate normal and abnormal embryonic development from the earliest stage as small as 4–5 weeks of gestation and hence is naturally the best method to detect OP at the earliest. It must however be remembered that a completely normal pelvic TVS scan may be present in 15–20% of patients with ectopic pregnancy. Hence, adequate follow-up and clinical correlation with serum human chorionic gonadotropin (HCG) values is a must.
Now-a-days, TVS scan is recognized as an essential diagnostic procedure for women during the early weeks of pregnancy in health as well as disease. In fact, TVS is reported to be more sensitive (88%) in the diagnosis of ectopic pregnancy than transabdominal ultrasound (TAS), which is 77% sensitive. Ovarian ectopic can cause complications like rupture and hemoperitonium, which may be difficult to differentiate from. This can be caused before the end of the first trimester. It is important to distinguish primary ovarian pregnancy from tubal pregnancy and hemorrhagic ovarian cyst because they have the same symptoms.
| Case Report|| |
A recently married 24-year-old female was referred for ultrasound of the abdomen and pelvis as she was suffering from dull aching pain in the right lower abdomen for the last 2 days. Clinically, her vitals were stable. Her systemic examination was within normal limits. She had missed her regular periods for the last 2 months. Her urine pregnancy test (UPT) was also positive.
Ultrasound of her abdomen was within normal limits. On TAS, her uterus was empty and the endometrium was 11 mm thick. No intrauterine or extrauterine gestational sac was seen. For better visualization of the uterus, an adnexal TVS scan was performed. A normal left ovary was demonstrated. To our surprise, the right ovary demonstrated a gestational sac with a small embryonal pole of 6 weeks' size. No fetal cardiac activity could be demonstrated even on color Doppler [Figure 1]. There was no free fluid in its vicinity. There was significant probe tenderness over the right ovary and there was focal increase in vascularity. Thus, in the given clinical context, an ultrasound diagnosis of unruptured right ovarian ectopic was offered.
|Figure 1: Transvaginal ultrasound image with color Doppler shows right ovarian ectopic pregnancy. Embryonal pole devoid of cardiac activity is seen (vertical arrow pointing downwards) and few ovarian follicles (horizontal arrows pointing toward the right of the image) are also seen|
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Within 1 h, her pain worsened and she was taken up for surgery in which the right ovary showed a gestational sac of 25 mm × 28 mm in the process of rupture. It was removed and the ovary was cauterized. Samples were sent for histopathological analysis, which demonstrated the presence of trophoblastic tissue with chorionic villi in the ovarian tissue [Figure 2] and confirmed this to be a case of right ovarian ectopic.
|Figure 2: Histopathology slide (hematoxylin and eosin stain) showing chorionic villi amidst the hemorrhagic area in the ovarian tissue|
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| Discussion|| |
The reported incidence of EP is between 95% and 97% in the fallopian tube, <5% in the uterine cornu and around 1% within the ovary. OP develops following secondary implantation or failure of follicular extrusion, which is generally believed to be a result of reverse migration of embryos as a result of deep deposition of the embryos into the uterine cavity or the use of a large volume of culture fluid during transfer.
Multiple risk factors are known that can make a lady more prone to EP, and they are prior ectopic gestation, genital infections, prior tubal surgery, use of ovulation induction agents and, last but not the least, the use of assisted reproductive techniques. However, OP is believed to be a random event that is not associated with these risk factors as was seen in our case.
Clinically, presentations are variable. This range includes a totally asymptomatic lady, a lady with pelvic pain of different degrees or even total collapse. She may have pallor and signs of hypotension.
Diagnosis is usually made on a clinical suspicion of missed period, a positive UPT and pelvic pain. Role of imaging is to confirm the clinical suspicion and to rule out other associated causes of pain in that region, like ureteric calculus, lymphadenopathy, colitis and even appendicitis or abscess.
There are a number of reported cases with a variety of presentations, many of them having difficulty in diagnosis and management of this entity. Bontis et al. described a case of an intrafollicular ovarian pregnancy after ovulation induction and intrauterine in a primary infertility case of 4 years. Diagnostic laparoscopy revealed endometriosis and adhesions. After adhesiolysis and laser vaporization of endometriotic implants, the patient underwent ovulation induction with artificial insemination by husband/intrauterine insemination; she conceived at her second attempt. The pregnancy proved to be an ovarian intrafollicular one. She was treated by right partial ovariectomy. The diagnostic problems resulting from the coexistence of ovarian hyperstimulation and the intrafollicular development of pregnancy are thus complex. Kraemer et al. published a case of a vital ectopic pregnancy after 8 weeks that was located in the right ovary. A 29-year-old primigravida presented with lower abdominal pain and mild vaginal bleeding at 8 weeks after her last menstrual period. Although the embryo was laparoscopically removed in toto and visualized, they realized that pre-operative diagnosis of this extremely rare condition is challenging because the ectopic tumor often resembles cysts of the corpus luteum. At surgery, the trophoblast tissue or the embryo can rarely be visualized completely.
Ultrasound is the most widely used imaging modality as it gives exquisite details and is widely available. Its non-invasive, radiation-free as well as portable nature makes it the modality of choice in such condition. Finding a normal intrauterine gestational sac is the surest way to rule out the chances of any EP. It must however be remembered that, very rarely, an EP can coexist along with a normal intrauterine gestation. An early gestational sac is located within the decidua, as opposed to the decidual cast that is located within the endometrial cavity. A pesudogestational sac can be differentiated from a true intrauterine gestational sac as it is elongated, whereas an intrauterine gestational sac is eccentric, round or oval in shape.
The decidual reaction is usually less than 2 mm in the pseudogestational sac, and is more than 6–8 mm in normal intrauterine pregnancy. Presence of echogenic free fluid increases the possibility of EP as it is seen in 28–56% of patients. OP typically shows a more echogenic white ring in the ovary compared with the ovarian tissue, with a yolk sac or fetal parts being the key ultrasonography indicators of ovarian ectopic; however, an embryo is relatively infrequently seen. The closest differentials of OP are a hemorrhagic ovarian cyst or a corpus luteal cyst. But, the clinical context often enables the differentiation.
In order to label any EP as OP, the following criteria must be fulfilled:
- The fallopian tube with its fimbriae should be intact and separate from the ovary
- The gestational sac should occupy the normal position of the ovary
- The gestational sac should be connected to the uterus by the utero-ovarian ligament
- The ovarian tissue must be preserved in the specimen attached to the gestational sac.
Medical management consists of use of methotrexate or PGF2 in cases of primary incomplete resection or trophoblastic persistence, but laparoscopic ovarian wedge resection or cystectomy is the mainstay of treatment for OP.
The key to timely management and successful outcome in OP is the early detection and a high index of suspicion. Although TVS usually solves the diagnostic dilemma, it must be borne in mind that ultrasonography is an operator-dependant modality. Sometimes, when ultrasound is equivocal, follow-up TVS scans and serial β-human chorionic gonadotropin level at or after 48 h are required to confirm the clinical suspicion.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]